1. Background
Drug addiction poses such complicated threats to society that only a few other phenomena could be classed as menacing (1). Approximately, a quarter of the world population have experienced drug and 15% have suffered from drug-induced diseases (2). Over the recent years, addiction has had an increasing trend around the globe and, by extension, in our country. According to the statistics, roughly 73% of the addicts in the world are under 40 years of age and have an average age of about 35 years old. The presence of 2.5 million registered and about 4 million occasional addicts requires due attention and efforts to curb and overcome this undesirable phenomenon (3). Different studies in Iran have reported various statistics regarding the number of drug addicts, ranging between 1.7% and 2.5% of the entire population (4, 5). The age for drug addiction has decreased drastically in Iran during the past two decades, reaching younger than 20 years and in some cases even 8 years old (6). Different factors are cited as the predisposing factors to addiction, including the high rate of familial conflicts, education problems, simultaneous appearance of mental disorders such as conduct disorder and depression, drug abuse by peers and parents, impulsivity, and early onset cigarette smoking. A higher number of these risk factors in an individual will invariably raise the likelihood of drug abuse (7). One of the important aspects of addiction observed during preventive efforts is the relapse of substance behavior after a period of abstinence. Many studies have demonstrated high prevalence rates of return to addiction such as 66% during the first 6 months, 20 - 50% after one year, and 19% during the first 6 years following attempted abstinence (8). In a study in Taiwan, the rate of addiction relapse after attempts at quitting was reported at 70%. In Iran, based on the available data, 50% of the addicts having referred to rehabilitation centers for quitting have a history of at least one attempt at quitting, which underscores the high rate of addiction relapse after unsuccessful abstinence (9). Abundant studies have been conducted on follow-up treatment and the reasons for relapse and reconsumption of opioids. According to Gastfriend (1996), Pani, Trogu, and Contu (1998), comorbid disorders like depression, anxiety, schizophrenia, and drug addiction cause resistance to treatment and return to drug abuse (10). In addition, according to the psychoanalysis approach, drug abuse helps the youth to control their unconscious impulses and needs. Moreover, many youths tend to gravitate to drug abuse in order to cope with stress (11).
Joe, Simpson, and Broome (1998) reported that variables such as preparation or motivation for treatment, demographic characteristics, duration of drug abuse, criminal record, combined psychiatric disorders, and history of previous treatment are factors affecting the relapse rate (12). With respect to the role of the family and on factors effective in return to alcohol addiction, Miller, Harris, and Westerberg (1996) mentioned the 5 variables of negative occurrences and events in life, cognitive appraisal, adaptation resources, drug cravings, and affective/mood status (13). Elsewhere, Catalano et al. (1999) emphasized the role of family relationships in return to addiction (14). Also Sheehan et al. (1993) reported the determining factors of treatment outcomes as job creation, social status, and mental health improvement (15). Sadock (2000) remarked that the addiction of a first-degree relative is one of the factors effective in addiction relapse (16). In the studies conducted in Iran, the results have shown that interpersonal factors such as relationships with addicted and misleading friends, unemployment, and poverty and familial factors such as the inappropriate behavior of the family exert a significant impact on addiction relapse (17). In a study conducted by Sayyadi et al. (10), there was a significant difference between the successful and unsuccessful groups in terms of the factors influencing the outcome of quitting addiction, including age, employment, spouse, private house, kind of the drug consumed, way of usage, amount used per day, age at starting addiction, experience of using any kind of drug, history of injection, and history of quitting (18). Considering the increasing trend of addiction among the young population in Iran and the high rate of return to addiction after quitting, it is necessary to conduct more studies to detect the factors correlated with treatment failure and addiction relapse with a view to devising effective prevention and control strategies. So formidable are the negative influences of addiction on the growth and prosperity of society that any attempt at determining the predisposing factors to return to addiction should be tremendously encouraged.
2. Objectives
The objective of this study was to determine what factors (personal, familial, or social) are correlated with addiction relapse.
3. Patients and Methods
This research is a descriptive study on all addicts who referred to the addiction treatment centers of Ahvaz. The inclusion criteria were comprised of being between 15 and 60 years old, having at least one history of relapse, being able to speak in Persian, and willingness to participate in the research. In this study, the sampling method was purposive and non-randomized. After conducting the primary study on 20 cases and using the formula for calculating the sample size, 146 persons were determined. For data collection, the first researcher provided the participants with a comprehensive explanation about the objective of the study and gave them reassurances about the confidentiality of their information. After the subjects signed an informed written consent, they were asked to fill in a questionnaire. Data collection lasted for 3 months, and the tool for collecting the data was a researcher-made questionnaire consisting of two parts: basic demographic information and personal information. The part on basic demographic information consisted of 19 questions, including age, sex, occupation, education, family status, place of living, and marital status, and the portion on personal information consisted of 10 components related to physical problems, 10 components associated with personal-mental health factors, 4 components relevant to social-interpersonal factors, 11 components regarding social-occupational factors, and 14 components on familial factors. A 4-point Likert scale with the following values was used to survey the components of the personal information part: always: 3; sometimes: 2; rarely: one; and never: 0. The validity of the questionnaire was evaluated via the content validity method under the guidance of 10 faculty members of Ahvaz Jundishapur University of Medical Sciences. The split-half method and Cronbach’s alpha method were employed to determine the reliability. In the primary study, 20 questionnaires were surveyed and the alpha coefficient for the questionnaire was 0.92, showing the high reliability of the measurement tool. After data collection, the data were analyzed using SPSS software (version 17) and descriptive statistics.
4. Results
Considering the information achieved by analyzing the data, 46.1% of the samples were in the age group of 20 to 30 years old, 52.9% were single, 33.3% had irregular part-time jobs, 27.4% were unemployed, 53.4% had educational levels below the high-school diploma, and 55.1% had private homes. Regarding the methods used for treating addiction, 62.5% of the participants consumed known drugs under the physician’s supervision. Also, 61.5% of the samples had a drug abstinence period of between one and 6 months. Relationship with misleading friends as the chief reason for drug reconsumption was reported by 47.3% of the study population. As the principal reason for reattempt at treatment, 48.2% of the individuals cited stress. Furthermore, 63.9%, 71.2%, and 79.7% of the samples did not mention a history of mental illness, use of psychiatric drugs, presence of chronic medical diseases interfering with everyday life, and positive history of using a special drug, respectively. Fifty percent of the individuals had a positive record of imprisonment; the majority of these individuals (39.2%) had served a prison sentence of between 6 and 12 months' duration. Most of the samples (54.2%) had a history of addiction less than one year. Also, 63.4% of the subjects did not use injective drugs; however, the maximum age for starting drug injection (44.2% of the cases) was between 20 and 28 years old. In addition, the most frequent physical problems reported by the samples were loss of appetite (23.9%), numbness and pins and needles (23.3%), and joint/bone pain (22.4%), respectively. The most important personal-mental health factors reported by the subjects were feeling of loneliness (44%), hopelessness (35.6%), and uninterestedness in everything (35.6%), correspondingly. The data on social-interpersonal, social-occupational/economic, and familial factors are depicted in Tables 1, 2, and 3.
Table 1. Frequency Distribution and the Percentage Related to Personal Information (Social-Interpersonal Factors)
| Factor or Characteristic | Never | Seldom | Sometimes | Always |
|---|---|---|---|---|
| Relationship with addicted or misleading friends | 42 (8.32) | 26 (3.20) | 15 (7.11) | 45 (35.2) |
| Relationship with addicted coworkers | 41 (3.33) | 22 (9.17) | 23 (7.18) | 37 (30.1) |
| Not being accepted by friends and society | 40 (5.31) | 24 (9.18) | 24 (9.18) | 39 (30.7) |
| Custom of consuming special drugs in society | 50 (3.41) | 26 (5.21) | 19 (7.15) | 26 (21.5) |
Table 2. Frequency Distribution and the Percentage Related to Personal Information (Social-Occupational and Economic Factors)
| Factor or Characteristic | Never | Seldom | Sometimes | Always |
|---|---|---|---|---|
| Unemployment | 38 (4.28) | 34 (4.25) | 26 (4.19) | 36 (26.9) |
| Not having interest in the job | 31 (7.23) | 34 (26) | 28 (4.21) | 38 (29) |
| Problems of job and occupation | 35 (5.28) | 23 (7.18) | 22 (9.17) | 43 (35) |
| Not having a permanent job | 28 (9.21) | 21 (4.16) | 24 (8.18) | 55 (43) |
| Frustration and failure in work-related issues | 30 (4/23) | 28 (9.21) | 23 (18) | 47 (36.8) |
| Long working hours | 26 (3.21) | 24 (7.19) | 26 (3.21) | 45 (36.9) |
| Excessive and exhausting work | 27 (6.21) | 21 (8.16) | 42 (6.33) | 35 (28) |
| Poverty | 41 (3.32) | 28 (22) | 22 (5.16) | 37 (29.1) |
| Buying and selling drugs to earn a living | 63 (4.50) | 14 (2.11) | 29 (2.23) | 19 (15.2) |
| Low cost of opioids | 48 (39) | 26 (1.21) | 20 (3.16) | 29 (23.6) |
| Burden induced by life costs | 31 (6.24) | 20 (9.15) | 28 (2.22) | 47 (37.3) |
Table 3. Frequency Distribution and Percentage Related to Personal Information (Familial Factors)
| Factor or Characteristic | Never | Seldom | Sometimes | Always |
|---|---|---|---|---|
| Inappropriate behavior of the family | 37 (4.27) | 40 (6.29) | 27 (20) | 31 (23) |
| Discrimination in the family | 38 (6.28) | 36 (1.27) | 27 (3.20) | 32 (24.1) |
| Absence of a proper relationship in the family | 35 (7.26) | 28 (4.21) | 26 (8.19) | 42 (32) |
| Crowdedness of the house | 42 (8.31) | 21 (9.15) | 28 (2.21) | 41 (31.1) |
| Pressure caused by bachelorhood | 46 (2.36) | 34 (8.26) | 24 (9.18) | 23 (18.1) |
| Loss or absence of the father | 51(1.41) | 28 (6.22) | 21 (9.16) | 24 (19.4) |
| Illiterate or unlearned mother | 53 (1.43) | 21 (1.17) | 19 (4.15) | 30 (24.4) |
| Improper behavior of the spouse and children | 57 (9.47) | 26 (8.21) | 22 (5.18) | 14 (11.7) |
| Infidelity of the spouse | 64 (7.55) | 19 (5.16) | 12 (4.10) | 20 (17.4) |
| Disagreement with the spouse | 51 (7.44) | 25 (9/21) | 16 (14) | 32 (19.3) |
| Conflict induced by marital issues | 55 (8.47) | 16 (9.13) | 18 (7.15) | 26(22.6) |
| Improper behavior of the spouse's family | 51 (7.44) | 19 (7.16) | 19 (7.16) | 25 (21.9) |
| Addiction of the relatives | 55 (5.45) | 25 (7.20) | 13 (7.10) | 28 (23.1) |
| Forced marriage | 79 (2.71) | 13 (7.11) | 11 (9.9) | 8 (7.2) |
5. Discussion
Return to addiction in an individual after attempts at cessation is an extremely formidable challenge that frustrates health care workers in their efforts to help the addict quit (19). Our results revealed high rates of failure in attempts at addiction treatment. Indeed, some of our subjects had tried 35 times to quit their substance abuse in vain.
Most of the addicts in the present study were adults aged between 20 and 30 years from the viewpoint of age prevalence. These results are consistent with the statistics presented by the Iranian National Drug Control Headquarters inasmuch as it reports the highest rate of addiction in individuals aged between 20 and 29 years (19).
In the present study, most of the participants (52.9%) were single, which is different from the results of previous studies conducted in Iran. The studies by Amini et al. (20) and the Iranian National Drug Control Headquarters (17) showed that 71.8% and 70% of the addicts were married, respectively. In contrast, the findings of a study by Cleveland et al. (18) (2007) are consistent with the results of the present study insofar as 84% of the participants were single in that study. Nevertheless, considering that the participants in the said study were young (mostly below 30 years old), it is to be expected that the study population consisted mainly of single individuals.
In the current study, 94.9% of the samples were men and 5.1% were women. Sadeghiyeh Ahari et al. (8) stated that men accounted for the bulk of their samples because of the conventional patriarchy and the tendency of addicted women to quit in private centers. Accordingly, the fact that the majority of our study population was comprised of men can be explained by the higher frequency of addiction among men and the relevant infeasibility of identifying female addicts in our country.
Our results showed that 71.4% of the individuals were illiterate or had educational levels below the high-school diploma. It is believed that quitting school results in the feelings of failure and frustration (7), predisposing the individual to high-risk behaviors.
Regarding the number of attempts at quitting addiction, 57.5% of our samples had a history of one to 6 attempts and 21.5% more than 12 attempts. In the studies by Din Mohammadi et al. (2) and Raoufi et al. (21), 42% and 49.4% of the subjects had at least one experience of quitting drugs, correspondingly.
Our data on physical factors relevant to addiction relapse showed that physical problems such as loss of appetite (23.9%), numbness and pins and needles (23.3%), and joint/bone pain (22.4%) were among the principal factors from the viewpoint of the addicts who had participated in the study. In another study (22), 13% of the studied population complained of gastrointestinal disorders. Given that these physical complaints and the efforts to relieve these problems are among the factors influencing return to addiction, it is necessary that due attention is paid to addiction treatment programs and their therapeutic methods with a view to reducing their failure rates.
Concerning the mental factors allied to the relapse of addiction, most of the complications in our study population were related to feeling of loneliness (44%), frustration (35.6%), and uninterestedness in everything (35.6%). Additionally, 48.2% of the subjects reported stress as the principal reason for their return to addiction. These statistics indicate that psychological and mental problems should be ranked among the most important reasons behind drug abuse relapse. Of all our subjects, 63.9% reported no history of psychological diseases or the use of psychological drugs, which underscores the significance of programs aimed at not only raising awareness among individuals to refer to psychiatrists and psychologists in order to seek treatment for their psychological and mental problems but also bolstering the pronounced presence of specialists in addiction treatment centers. In a study by Hasanshahi et al. (11) 25 - 40% of the subjects reported mental disorders, the most significant of which were depression, anxiety, antisocial personality, and psychosis. Among the interpersonal factors in that study, relationship was reported as the most important predisposing factor to return to addiction.
Our results concerning social factors (occupational-economic) showed that not having a permanent job (43%), followed by burden of life costs (37.3%), was the most important occupational-economic factor in the relapse of addiction. Economic status bears a close relationship with the tendency toward addiction and its relapse. In the Razaqi et al. study, most of the participants (80%) were workers with difficult jobs. The authors concluded that not having a proper job and unemployment not only undermines one's ability to provide the necessities of life and succeed in terms of material welfare but also begets disorders in asserting one's personality and power and diminishes hope for the future. These factors are liable to create a higher tendency toward high-risk behaviors such as addiction. There is a significant relation between unemployment and addiction. Unemployment and the concomitant lack of income are known as factors contributing to higher crime rates. Our results revealed that 50% of the participants had records of arrest and imprisonment. This direct relationship between addiction and crime has been previously described in a study conducted in America (23).
In the current study, with respect to familial factors, the most important reason for addiction relapse was the absence of a proper relationship in the family. Amini et al. (20) reported that the familial factors related to relapse in single persons and in married persons were the improper behavior of the family (100%) and the spouse and children (74.1%), respectively. Family and especially parents always play a significant role in the tendency toward addiction. Enjoying a close relationship with parents and receiving their spiritual and mental support decreases gravitation toward drug abuse. Indeed, family is the principal center of controlling one’s behavior; vulnerability in this respect, not least among the youth, can have serious ramifications in terms of addiction.
Our results clearly demonstrate the high rate of failure in attempts at addiction cure. This issue highlights the need to purposefully address the background problems of addicts and to raise awareness among the youth and their families about the complications of addiction and its predisposing factors. Battling addiction requires that the problems and predisposing factors of addiction be targeted by addiction programs because as long as the predisposing factors are present, the efforts of patients and authorities will come to no fruition and this sense of frustration and hopelessness will be the ruination of many resources.
In light of the results of the present study and other investigations, it is obvious that return to addiction and treatment failure is complicated and multifaceted issues. Without appropriate focus on these different aspects, campaigns against addiction are doomed to failure. The strongest point of the current study is that it provides information on factors influencing return to addiction, which can serve as the basis for further studies in this field. However, future studies are recommended with stronger designs (e.g. case-control) and randomized sampling to clearly determine the factors effective in return to addiction.
